Constipation may occur during chemotherapy as a side effect of medications, inactivity, untreated pain, high stress level, decreased fluid intake and decreased insoluble fiber intake.
Chemotherapy agents, narcotics (Tylenol #3,Percocet, Dilaudid), NSAIDS, anticholinergics, potassium-wasting diuretics, iron supplements, antidepressants, anesthetics, and antiemetics (Zofran, Aloxi), which may be commonly used during treatment, have the potential to cause constipation, especially when combined with other factors as listed. Overuse of laxatives may also cause constipation.
Interventions:
Due to pain, fatigue and discomfort, may be avoided. Performing range of motion, ambulating to bathroom or to a chair is effective to utilize abdominal muscles adequately to encourage intestinal movement.
Decreased fluid intake causes stools more compact and colon less lubricated. Increasing intake not only is said to decrease symptoms of constipation, but staying hydrated and avoiding dehydration has generalized positive effects on the majority of body systems.
To reduce symptoms, encouraging alternative pain management techniques, such as non-narcotic medications, meditation and guided imagery may assist with pain control and enable a reduction in narcotic use. If pain is controlled most effectively by narcotics or if a medication cannot be discontinued due to necessity, increasing activity level, fluid and fiber intake and utilizing fiber intake, laxatives or suppositories as indicated by doctor may be the best interventions available. Initial treatment varies by symptomology, doctor’s preference and patient’s prior experience. Example of treatment flowchart.
The first and most common foundational method of therapy includes bulking laxative agents (which includes increased fiber intake). Insoluble fiber bulks up stool to help it pass quickly when taken with adequate fluid intake. Increasing intake of soluble and insoluble fiber slowly to the recommended combined value of 25g for women and 38g for men as directed by doctor may decrease constipation. Items high in insoluble fiber include wheat bran, whole grains, cereals, seeds and skins of fruits and vegetables including broccoli, prunes and beans. If increased intake is made difficult by decrease in appetite, anorexia or nausea,psyllium powder and other over-the counter bulk-forming agents (such as Metamucil) are available for supplementation. Supplementation usually works within 12-24 hours, but varies depending on individual intestinal motility. Increasing fluid intake to at least 2L/day is vital to supplement fiber intake; fecal impact, a medical emergency, could occur without more liquids.
Stimulant laxatives (Senna Extract {Senokot}, Correctol and Ex-Lax) may be combined with bulking agents.
Stool softeners (ex. Colace and Docusate Calcium) are used to keep the stool saturated with water, aiding in ease of evacuation.
Osmotic laxatives similarly keep stool soft by keeping water in stool by use of non-absorptive sugar additives but also pull water into intestines from systemic sources.
Cathartics are utilized for deep cleansing of bowel when x-ray, history of constipation and inability to spontaneously evacuate a moderate-size amount of stool is present.
Suppositories and enemas are utilized when pressure is present in the rectum and the client may only need help initiating a bowel movement. Water and oil-based enemas are administered to lubricate and initiate “fullness” in the rectum to inspire mechanical reaction. Suppositories and enemas are effective almost immediately after administration and may create a safety issue related to urgency to get to a toilet. Interventions include having a bed pan to reduce need to immediately ambulate, monitor environment for safety and proper furniture/cord placement.
Dietary changes and supplementation should be made under consultation of a doctor.
Diarrhea
Causative factors:
Cancer treatment (chemotherapy, radiation, bone marrow transplantation, surgery), cancer itself, antibiotic therapy, stress, anxiety, infection, diet, and laxative regime.
Interventions:
Identify the underlying cause (diet, infection, graft-versus-host-disease, etc) and treat.
Diet changes such as the BRAT diet (bananas, rice, apples, toast)
Probiotics
IV fluid replacements for severe diarrhea
Hand hygiene
Carefully monitor intake and output and how well food/drink is tolerated
Assessment for Diarrhea and Constipation:
I&O- Increase intake for constipation therapy; increase/decrease according to needs with diarrhea. Monitor carefully for both.
Causative factors of diarrhea or constipation: take history of symptomology, note medications and treatments, food intolerance, decrease in activity level, level of stress, change in routine, recent travel, decrease or increase in water intake or presence of infectious agent.
Stool consistency and qualities; time and date of last bowel movement; any presence of blood
Abdominal assessment: Auscultation, bowel sounds, palpation and pain assessment
Hydration status: skin turgor and color, mucous membrane color and moistness, capillary refill, quality of peripheral pulses, level of consciousness and neurologic assessment, recent weight loss or gain
Skin assessment r/t diarrhea- Braden Scale
Effectiveness of administered medications or interventions
Side effects of administered medications: For anti-diarrheal, constipation.
For laxatives, diarrhea.
For bulk-forming laxatives, increased constipation.
Safety: Keep environment free of clutter for a safe passageway to bathroom; recommend use of bed pan or commode to eliminate ambulation needs if weak or experiencing extreme bowel urgency; Monitor hydration status.
Constipation
Causative factors:
Constipation may occur during chemotherapy as a side effect of medications, inactivity, untreated pain, high stress level, decreased fluid intake and decreased insoluble fiber intake.
Chemotherapy agents, narcotics (Tylenol #3,Percocet, Dilaudid), NSAIDS, anticholinergics, potassium-wasting diuretics, iron supplements, antidepressants, anesthetics, and antiemetics (Zofran, Aloxi), which may be commonly used during treatment, have the potential to cause constipation, especially when combined with other factors as listed. Overuse of laxatives may also cause constipation.
Interventions:
Due to pain, fatigue and discomfort, may be avoided. Performing range of motion, ambulating to bathroom or to a chair is effective to utilize abdominal muscles adequately to encourage intestinal movement.
Decreased fluid intake causes stools more compact and colon less lubricated. Increasing intake not only is said to decrease symptoms of constipation, but staying hydrated and avoiding dehydration has generalized positive effects on the majority of body systems.
To reduce symptoms, encouraging alternative pain management techniques, such as non-narcotic medications, meditation and guided imagery may assist with pain control and enable a reduction in narcotic use. If pain is controlled most effectively by narcotics or if a medication cannot be discontinued due to necessity, increasing activity level, fluid and fiber intake and utilizing fiber intake, laxatives or suppositories as indicated by doctor may be the best interventions available. Initial treatment varies by symptomology, doctor’s preference and patient’s prior experience. Example of treatment flowchart.
The first and most common foundational method of therapy includes bulking laxative agents (which includes increased fiber intake). Insoluble fiber bulks up stool to help it pass quickly when taken with adequate fluid intake. Increasing intake of soluble and insoluble fiber slowly to the recommended combined value of 25g for women and 38g for men as directed by doctor may decrease constipation. Items high in insoluble fiber include wheat bran, whole grains, cereals, seeds and skins of fruits and vegetables including broccoli, prunes and beans. If increased intake is made difficult by decrease in appetite, anorexia or nausea,psyllium powder and other over-the counter bulk-forming agents (such as Metamucil) are available for supplementation. Supplementation usually works within 12-24 hours, but varies depending on individual intestinal motility. Increasing fluid intake to at least 2L/day is vital to supplement fiber intake; fecal impact, a medical emergency, could occur without more liquids.
Stimulant laxatives (Senna Extract {Senokot}, Correctol and Ex-Lax) may be combined with bulking agents.
Stool softeners (ex. Colace and Docusate Calcium) are used to keep the stool saturated with water, aiding in ease of evacuation.
Osmotic laxatives similarly keep stool soft by keeping water in stool by use of non-absorptive sugar additives but also pull water into intestines from systemic sources.
Cathartics are utilized for deep cleansing of bowel when x-ray, history of constipation and inability to spontaneously evacuate a moderate-size amount of stool is present.
Suppositories and enemas are utilized when pressure is present in the rectum and the client may only need help initiating a bowel movement. Water and oil-based enemas are administered to lubricate and initiate “fullness” in the rectum to inspire mechanical reaction. Suppositories and enemas are effective almost immediately after administration and may create a safety issue related to urgency to get to a toilet. Interventions include having a bed pan to reduce need to immediately ambulate, monitor environment for safety and proper furniture/cord placement.
Dietary changes and supplementation should be made under consultation of a doctor.
Diarrhea
Causative factors:
Cancer treatment (chemotherapy, radiation, bone marrow transplantation, surgery), cancer itself, antibiotic therapy, stress, anxiety, infection, diet, and laxative regime.
Interventions:
Identify the underlying cause (diet, infection, graft-versus-host-disease, etc) and treat.
Diet changes such as the BRAT diet (bananas, rice, apples, toast)
Probiotics
IV fluid replacements for severe diarrhea
Hand hygiene
Carefully monitor intake and output and how well food/drink is tolerated
Assessment for Diarrhea and Constipation:
I&O- Increase intake for constipation therapy; increase/decrease according to needs with diarrhea. Monitor carefully for both.
Causative factors of diarrhea or constipation: take history of symptomology, note medications and treatments, food intolerance, decrease in activity level, level of stress, change in routine, recent travel, decrease or increase in water intake or presence of infectious agent.
Stool consistency and qualities; time and date of last bowel movement; any presence of blood
Abdominal assessment: Auscultation, bowel sounds, palpation and pain assessment
Labs: Serum electrolytes, HGB, HCT, BUN, creatinine, serum prealbumen
Hydration status: skin turgor and color, mucous membrane color and moistness, capillary refill, quality of peripheral pulses, level of consciousness and neurologic assessment, recent weight loss or gain
Skin assessment r/t diarrhea- Braden Scale
Effectiveness of administered medications or interventions
Side effects of administered medications: For anti-diarrheal, constipation.
For laxatives, diarrhea.
For bulk-forming laxatives, increased constipation.
Safety: Keep environment free of clutter for a safe passageway to bathroom; recommend use of bed pan or commode to eliminate ambulation needs if weak or experiencing extreme bowel urgency; Monitor hydration status.
References
http://cancer.about.com/od/chemotherapysideeffects/a/constipation.htm
http://cancer.about.com/od/chemotherapysideeffects/a/managediarrhea.htm
http://www.webmd.com/a-to-z-guides/nonprescription-medications-and-products-bulking-agents-and-laxatives
http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/Patient/page6
Nursing ArticleConstipation [electronic resource]: etiology, evaluation and management [edited by] Steven D. Wexner and Graeme S. Duthie. https://i-share.carli.illinois.edu/wrh/cgi-bin/Pwebrecon.cgi?SC=CallNumber&SEQ=20120122100240&PID=49mxfcmxFY5sgQDpUXXo9-4&SA=RC861+.C664+2006eb
Etiology of Aquired Colorectal Disease: Constipation by Peter J. Deveaux and Susan Galandiuk. http://dx.doi.org/10.1007/978-1-84628-275-1_3
Medical Treatment of Constipation by Raymond B. Sandler, Benjamin Person and Ramu Raju. http://dx.doi.org/10.1007/978-1-84628-275-1_14
Cancer-related diarrhea: Selected findings of a national survey of oncology nurse experiences. by Rutledge, D.N., and Engelking C.
http://www.ncbi.nlm.nih.gov/pubmed/9644702